3 : Past Surgical History Past Sinus Surgery YES NO If yes, when? Past Tonsil Surgery YES NO If yes, when? Tubes in Ears YES NO If yes, which ear? Left Right Other Surgeries: Family Medical History Allergic Rhinitis Eczema Asthma Food Allergy Other Mother Father Grandparent Sibling Child Social History Alcohol Use: FREQUENT SOCIAL NEVER Previous history of Alcohol use: Tobacco Use: CIGARETTES CIGAR CHEW CURRENT SMOKER: Packs per day: FORMER SMOKER: Packs per day: NEVER SMOKED Caffeine Use: FREQUENT SOCIAL NEVER Type of caffeine: Allergies Known Food Allergies: YES NO If yes, what? Known Pet Allergies: YES NO If yes, what? Known Drug Allergies: YES NO If yes, what? Do you currently have a Medi-port? YES NO Current Medication Medication Strength Frequency Medication Strength Frequency

4 : Preferred Pharmacy Information Local Pharmacy: Cross Streets: Address: City: State: Zip: Telephone number: Fax number: Mail order Pharmacy: Address: City: State: Zip: Telephone number: Fax number: Office Policies All Co-payments and account balances are due at the time services are rendered, unless other arrangements have been made. We accept cash, check, Visa and MasterCard. Inform the front office receptionist of any changes in demographics or insurance. Failure to do so may lead to an account balance. If you have an insurance plan that requires a paper referral or authorization number, it is your responsibility to make sure the referral has been completed by your primary care physician and is in our office for your scheduled appointment time. If we do not have a referral or authorization your appointment can be rescheduled. Give at least 48 hours notice when canceling or rescheduling an appointment, so we may use that appointment for another patient. If you are late for your appointment the doctor will be unable to see you. There is a $50 fee for No Show appointments and same day cancellations. There is a $25 fee for All NSF Returned Checks. Please allow hours for your prescription to be refilled. PRESCRIPTIONS WILL NOT BE REFILLED OVER THE WEEKEND. Self-Pay I do not have health insurance and will be responsible for services rendered here at IMS AIS. I agree to pay IMS AIS, a division of IMS, the full and entire amount of treatment given to me or to the above named patient at each visit.

5 : Statement of Patient Financial Responsibility IMS AIS, A Division of IMS, appreciates the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill. You are responsible for payment of any deductible and co-payment/co-insurance as determined by your contract with your insurance carrier. We expect these payments at the time of service. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance denies any part of your claim, or if you or your physician elect to continue past your approved period, you will be responsible for your balance in full. Finance charges will begin to accrue on any unpaid patient responsibility balance after 90 days old. If you fail to make any payments for which you are deemed responsible for in a timely manner, after such default and upon referral to a collection agency or attorney by IMS, you will responsible for all cost of collecting moneys owed, including but not limited to court costs, collection agency and/or attorney fees. I have read the above policy regarding my financial responsibility to IMS AIS, for providing rehabilitative services to me or the above named patient. I certify that the information is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to, IMS AIS, a division of IMS, the full and entire amount of my bill incurred by me or the above named patient; or, if applicable any amount due after payment has been made by my insurance carrier. Co-Pay Policy Some health insurance carriers require the patient to pay a co-pay for services rendered. It is expected and appreciated at the time the service is rendered for the patients to pay at EACH VISIT. Thank you for your cooperation in this matter. Consent for Treatment and Authorization to Release Information I hereby authorize IMS AIS, a division of IMS, through its appropriate personnel, to perform or have performed upon me, or the above named patient, appropriate assessment and treatment procedures. I further authorize IMS AIS, and its affiliates, to release to appropriate agencies, any information acquired in the course of my or the above named patient s examination and treatment. Cancellation/No Show Policy We understand there may be times when you miss an appointment due to emergencies or obligations to work or family. However, we urge you to call 48 hours prior to your appointment to cancel. I understand if I no show for two consecutive appointments, no show for three appointments or cancel for a total of four appointments, I may be discharged for care. Our offices will notify you in writing, via mail, if you are discharged from care. I have read and understand the above information, and I agree to the terms described:

6 : QUESTIONS, CONCERNS OR COMPLAINTS If you have any questions or want more information about this Notice or how to exercise your privacy rights, please contact our Privacy Officer at or by mail at 9250 N 3 rd Street, Suite 4010, Phoenix, Arizona If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services (HHS). To file a complaint with us, you may contact our Privacy Officer. To file a complaint with HHS, you may contact the Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Ave. S.W., Room 509F HHH Bldg., Washington DC We will not retaliate against you for filing a complaint. Signature below is acknowledgement that you have read and understand this Notice. Patient Name: DOB: Signature: : RELEASE OF INFORMATION I hereby authorize IMS to release or discuss any and all information pertaining to myself or my medical records with the following people. Name: Relationship: Phone Number: Name: Relationship: Phone Number: Name: Relationship: Phone Number: I authorize IMS to contact me at: Home Phone: Work Phone: May we leave a message on machine? YES NO Cell Phone: Alternate Phone: : Witness: : :

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)

PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING

Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female

Dear Patient, Thank you for choosing San Antonio Center for Physical Therapy for your rehabilitation needs. We want your time with us to be a positive experience, one that leads you down a road of successful

(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last

Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST

MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form Front Office Person calls in for a new patient appointment. o Never seen at SWAN o Previously Seen at SWAN The following

Guardian/Patient Name Family Dental Care NC 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 Date/Initial SIGNATURE ON FILE I authorize use of this form on all my insurance submissions.

AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.

CONSENT FOR MEDICAL TREATMENT Patient Name DOB Date I, the patient or authorized representative, consent to any examination, evaluation and treatment regarding any illness, injury or other health concern

GFP GARDENS FAMILY PRACTICE Phone (561) 627-7433 Fax (561) 775-1055 Welcome To Gardens Family Practice! We are happy to have you join our family and would like to give you some general information regarding

Physical Therapy Services Medical History Form Last Name First Name DOB Age Diagnosis: Physician: Check Yes or No. If yes, please explain in the space provided. Yes No Are you pregnant? Yes No Currently

PAYMENT AGREEMENT: We accept most insurance plans as a courtesy. We encourage you to familiarize yourself with your individual plan. Insurance coverage is an agreement between patient and insurance company

Patient Name: Last First Address City State Zip Phone# (C) (H) (W) Date of Birth Social Security# (REQUIRED FOR BILLING) If Patient is a Minor, a Parent s Name & Social Security# are Required Emergency

Medical History Check YES or NO Have you or any immediate family member ever been told you have... Self... Family Cancer?... Yes No... Yes No Diabetes?... Yes No... Yes No High blood pressure?. Yes No...

Calais Dermatology Associates Please present ALL insurance cards to the receptionist. If patient is a minor, and you are not the legal guardian, please ask receptionist for minor paperwork. Patient Information:

Patient s First and Last Name / / PEDIATRIC MEDICAL HISTORY FORM PRESENT HEALTH CONCERN (Reason for today s visit.) ALLERGIES List all allergies to medications, foods and/or other agents. Medication/Food/Other

Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use

At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We

375 Sixth Street Dover, NH 03820 Tel (603) 749-0636 www.howarddental.com Hello from JD Howard Dental! On behalf of all the staff, we welcome you to our office. We are happy that you have selected us to

MEDICAL & OCULAR HISTORY QUESTIONAIRRE Name: Date: Age: Preferred Pharmacy Name: Address: 1. Please describe briefly the main reason you are being examined today. 2. Do you have any of the following conditions

Welcome to Cool Springs EyeCare and Donelson EyeCare! We are looking forward to seeing you and helping you with your eye health and vision. As a comprehensive primary care practice we provide a full range

Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions

17756 KATY FREEWAY STE G-1 PATIENT REGISTRATION Welcome and thank you for visiting our office today! My staff and I are committed to providing you with quality care. Please make yourself comfortable and